The Department of Health and NHS England have asked NICE to develop evidence‑based guidelines on safe staffing, with a particular focus on nursing and midwifery staff, for England. This request followed the publication of the Francis report (2013) and the Keogh review (2013).

Focus of the guideline

This guideline makes recommendations on safe midwifery staffing requirements for maternity settings, based on the best available evidence. The guideline focuses on the pre-conception, antenatal, intrapartum and postnatal care provided by midwives in all maternity settings, including: at home, in the community, in day assessment units, in obstetric units, and in midwifery-led units (both alongside hospitals and free-standing).

The guideline recommendations are split into different sections:

  • Recommendations in section 1.1 are aimed at trust boards, senior management and commissioners and identify organisational and managerial responsibilities to support safe midwifery staffing requirements.

  • Recommendations in section 1.2 are aimed at senior registered midwives (or other authorised people) who are responsible for setting the midwifery staffing establishment. They focus on the process for setting the staffing establishment and the factors that should be taken into account.

  • Recommendations in section 1.3 are aimed at senior registered midwives who are in charge of maternity services or shifts. They are about ensuring that the service or shift can respond to situations that may lead to an increased demand for midwives and to differences between the numbers of midwives needed and the numbers available.

  • Recommendations in section 1.4 are aimed at senior management and registered midwifery managers and are about monitoring whether safe midwifery staffing requirements are being met. This includes recommendations to review midwifery staffing establishments and adjust them if necessary.

For further information, see the scope for the guideline.

This guideline is for organisations that provide or commission services for NHS service users. It is aimed at policy decision makers, commissioners, trust boards, hospital managers, service managers, heads and directors of nursing and midwifery, midwives, and other healthcare professionals. It will also be of interest to regulators and the public.

In this guideline, the terms midwife and midwifery refer to registered midwives only. Maternity support workers or other staff working alongside midwives are not included in this definition.

Those responsible and accountable for staffing maternity services should take this guideline fully into account. However, this guideline does not override the need for, and importance of, using professional judgement to make decisions appropriate to the circumstances.

This guideline does not cover national or regional level workforce planning or recruitment, although its content may inform these areas.

This guideline does not address staffing requirements in relation to other staff groups such as maternity support workers, medical consultants, theatre nurses or allied health professionals, although we acknowledge that a multidisciplinary approach and the availability of other staff and healthcare professionals are an important part of safe staffing for maternity services. The guideline takes into account the impact of the availability of other staff groups on midwifery staffing requirements.

Toolkits to support this guideline

The guideline will also be of interest to people involved in developing evidence‑based toolkits for assessing and determining safe midwifery staffing requirements. NICE offers a separate process to assess whether submitted evidence‑based toolkits for informing staffing requirements comply with the guideline recommendations. Details of any toolkits that can help with implementing this guideline are listed alongside other resources.

Staffing ratios

A minimum staffing ratio for women in established labour has been recommended in this guideline, based on the evidence available and the Safe Staffing Advisory Committee's knowledge and experience. The Committee did not recommend staffing ratios for other areas of midwifery care. This was because of the local variation in how maternity services are configured and therefore variation in midwifery staffing requirements, and because of the lack of evidence to support setting midwife staffing ratios for other areas of care. Professional guidance, toolkits and other resources about midwifery staffing levels or ratios are available. However there was a lack of evidence regarding the effectiveness of existing toolkits and resources for calculating safe midwifery staffing.

The Committee's discussions about staffing ratios and toolkits are contained in the Evidence to recommendations tables that are published alongside the guideline (appendix 1). See section 3 and section 4 for further details about the gaps in the evidence on staffing ratios and research recommendations.